In 2014, the W.W. Caruth, Jr. Foundation at Communities Foundation of Texas awarded PCCI a groundbreaking grant through Parkland Foundation that will enable PCCI to build and implement the Dallas Information Exchange Portal (IEP). The Dallas IEP, a novel, electronic, real-time integration platform, will leverage existing technologies, strengthen community partnerships, and engage with existing regional health information exchange (HIE) efforts to connect community organizations not only to Parkland but also to healthcare providers across the Dallas-Fort Worth Metroplex.The Dallas IEP will enable a two-way exchange of social and health information to facilitate care coordination, improve disease management, and reduce readmissions for the most vulnerable patients across the medical and social service sectors. Using advanced analytics, artificial intelligence, and natural language processing (NLP) in the Pieces™ software system, the Dallas IEP will utilize the combination of clinical and social variables to predict adverse events and help facilitate the delivery of targeted interventions.

Lyda Hill Foundation

Intelligent Technology Deployments for the New Parkland Campus

In 2015, the Lyda Hill Foundation awarded PCCI, through the Parkland Foundation, a transformative grant to design and implement advanced technology solutions at Parkland Hospital to enhance patient safety, patient-centered care, and value-based care. The grant will further enable Parkland to reimagine and expand healthcare delivery through advanced technology and industry-leading analytics. Through the generous support for this work, PCCI continues to work with Parkland and the Dallas community to realize our vision of creating a world of connected communities where every health outcome is positive. This support will allow PCCI to reimagine and expand the knowledge base of healthcare through prescriptive analytics and artificial intelligence while delivering personalized and precision medicine to every individual at Parkland and beyond.

In 2017, Centers for Medicare and Medicaid Innovation (CMMI) awarded a $4.5 Million, 5-year grant to PCCI to implement the Dallas Accountable Health Communities (AHC) program. The Dallas AHC Program goals are to further leverage the Dallas IEP work to: 1) design and implement a uniform system of systematic screening, referral, and navigation for health-related social needs among Medicare and Medicaid beneficiaries; 2) achieve seamless care coordination and data sharing among healthcare providers and community service providers; and 3) positively impact population health and cost of care outcomes in Dallas. PCCI, who will serve as the bridge organization, has established an enthusiastic consortium including the Texas Medicaid Agency, five of the largest and most influential healthcare systems representing 1.57 million patient visits annually, 289 community service providers including two major umbrella organizations, and a mix of Medicaid HMO and private payers.

The National Institutes of Health

“Improving CKD Detection and Care in a High Risk and Underserved Population”

The National Institutes of Health generously awarded a collaborative research grant to the University of Texas Southwestern and Parkland Health & Hospital System toward establishing a new model of joint primary care/nephrology care to improve clinical management of risk factors for the progression of chronic kidney disease (CKD) and cardiovascular (CV) complications. This research will also focus on the expansion of disease-specific e-Model development for CKD. We are testing whether the use of Pieces™ will allow earlier detection of patients with CKD, especially among African-American and Hispanic populations, and facilitate earlier CKD care and preparation for renal replacement therapy.

Robert Wood Johnson Foundation (RWJF)

Data Across Sectors for Health (DASH)

In 2016, the Robert Wood Johnson Foundation (RWJF) awarded a $200,000, 18-month grant as part of its Data Across Sectors for Health (DASH) program. In this program, PCCI leverages the Dallas IEP platform to impact the food environment in Dallas by improving the dietary intake and nutritional status of patients who experience food insecurity and have been diagnosed with chronic diseases including diabetes and hypertension. The proposed collaboration, among PCCI, Parkland Health and Hospital System (PHHS) in Dallas, Texas and the North Texas Food Bank (NTFB) and its partner agencies (PAs), would impact not only the food environment, but also increase the coordination of care provided to the target community, and thus potentially improve both the quality of care provided and the self-management of chronic disease. The project would also enhance the already strong and growing ties among healthcare and social services providers in the region and could pave the way for further collaborative opportunities.

In 2010, the W.W. Caruth, Jr. Foundation at Communities Foundation of Texas awarded PCCI a visionary grant through Parkland Foundation to conduct a feasibility study and propose a design plan for an information exchange portal that would connect Parkland Health & Hospital System with social service organizations in Dallas in order to facilitate care transitions, improve disease management, and reduce readmissions for Parkland’s most vulnerable patients.

The National Institutes of Health

“Improving Chronic Disease Management with Pieces™”

PCCI and the University of Texas Southwestern Medical Center will implement a collaborative model between primary and subspecialty care in patients with multiple chronic conditions (diabetes mellitus, chronic kidney disease, and hypertension), using the Pieces™ platform. The study will be conducted in partnership with four healthcare systems: Parkland Health & Hospital System (Parkland) in Dallas, TX; ProHealth Physicians Group (ProHealth) in Farmington, CT; Texas Health Resources (Texas Health) in Arlington, TX; and Veterans Affairs North Texas Health Care System (VA) in Dallas, TX.The Pieces™ platform will utilize the electronic medical record (EMR) for data collection, early disease detection, and monitoring and care coordination for patients with chronic medical conditions. The grant builds on a 2011 NIH grant-funded project, “Improving CKD Detection and Care in a High Risk and Underserved Population,” in which Pieces™ identifies patients with CKD and assists in implementing recommended practices at Parkland.This project will be primarily overseen by the National Institute of Diabetes and Digestive and Kidney Diseases and secondarily by the National Heart, Lung, and Blood Institute.

As part of an NIH sponsored Clinical and Translational Science Award (CTSA), administered through the Center for Translational Medicine at the University of Texas Southwestern Medical Center (UTSW) in Dallas, PCCI will join a team of 62 medical research institutions working collaboratively to improve bench-to-bedside translational care across the country. The vision of UTSW CTSA is to accelerate the translation of new discoveries into clinical practice by integrating and centralizing clinical and translational research (CTR). Dr. Amarasingham, President and CEO of PCCI, will serve as the Director of Biomedical Informatics Program at UTSW, where he will spearhead the informatics effort with a particular focus on predictive modeling using electronic health record data. In addition, PCCI will conduct research to identify social and behavioral risk factors using EHR data as well as participate in innovate inter-institutional research projects and seminars.

The National Center for Advancing Translational Research

“UT-Southwestern Clinical and Translational Alliance for Research (UT-STAR)”

The National Center for Advancing Translational Research of the National Institutes of Health awarded joint grant funding in 2012 to the University of Texas Southwestern to provide the crucial infrastructure necessary for medical scientists to discover and apply new diagnostics and therapeutics for the detection, diagnosis, treatment and prevention of disease. PCCI is providing critical campus-wide informatics support for this grant.

The Agency For Healthcare Research and Quality

UT Southwestern Center of Patient-Centered Outcomes Research (PCOR)

The Agency for Healthcare Research & Quality (AHRQ) awarded joint grant funding to The University of Texas Southwestern Medical Center (UTSW) and PCCI, allowing UTSW to create an integrated Center for patient-centered outcomes research (PCOR) and comparative effectiveness research (CER) at UTSW, Parkland Health and Hospital System (Parkland), Children’s Medical Center (CMC), and the North Texas Veterans Administration Health Systems (Dallas VA). Investigators will harness data in the electronic medical record (EMR) to conduct observational and interventional studies to improve care for high risk, underserved patients and populations. Steve Miff, PhD, PCCI President and CEO, will serve as the Director of the Applied Medical Informatics Cluster for the PCOR Center. PCCI will play a valuable informatics coordination role for PCOR, developing new methods to predict readmissions using data from novel EMR sources previously untested.

United Way of Metropolitan Dallas GroundFloor Program

Pieces Catalyst: PCCI Pilot Payment Model for Integrated Health and Social Service

PCCI is developing Pieces Catalyst, a novel financial model that will realign incentives across social and clinical services sectors to enhance care provision to the Dallas community. Partending with Parkland Health & Hospital System and The Bridge North Texas, a Dallas-based homeless recovery center, this pilot will encourage utilization of existing social resources to holistically address patient health. Pieces Catalyst will revolutionize collaborative care, reinforce capacity building within community organizations, and drive collective community impact.

The Commonwealth Fund

“The Potential of Shared Savings Models to Support Integrated Health and Social Services for Complex Patients”

In addition to a range of clinical services, complex patients also often require social services to address housing, food, and other needs. All of these services need to be well integrated. One way to foster joint accountability for the health outcomes and costs of caring for this population is to establish arrangements between providers and community-based organizations in which the financial savings generated by improvements to efficiency and quality are shared. With grant support from The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy, PCCI will examine existing shared-savings arrangements across health care and other sectors to identify design principles required for success, such as those for calculating savings, setting appropriate savings time frames, and sharing savings among participating organizations. The project findings will set the stage for future implementation and evaluation of shared-savings models in the Dallas–Fort Worth area..

The Commonwealth Fund

“Developing a Clinical Decision Support Tool to Prospectively Identify Patients at High Risk for Hospital Readmission”

The expansion of our congestive heart failure (CHF) readmissions model into an automated all-cause e-Model is generously supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The all-cause model identifies patients at high risk for 30-day readmission within 24 hours of care and subsequent hospitalization, using data collected from 8 hospitals with disparate patient populations.

Gordon & Betty Moore Foundation

“Automating Identification of Patients at a High Risk for Readmission”

The prestigious Gordon and Betty Moore Foundation awarded a grant to PCCI to transform PIECES™ into a robust generalizable and exportable software platform that has new artificial intelligence features.

Gordon & Betty Moore Foundation

“Framework and Action Plan for Predictive Analytics”

The Gordon and Betty Moore Foundation generously awarded a grant to PCCI to form a collaboration of internationally renowned informaticists, health services researchers, statisticians, and legal and ethical experts to identify how the use of real-time healthcare predictive analytics can make the greatest positive impact on patient outcomes and costs. In support of the Foundation’s Patient Care Program strategy, these experts will come together in Washington DC in an action-oriented, outcomes focused meeting designed to create clarity and momentum for healthcare predictive analytics to improve the quality, safety, and cost of healthcare.

We are grateful to The National Cancer Institute for their grant to the University of Texas Southwestern and Parkland Health & Hospital System for a collaborative endeavor to optimize colon cancer screening through personalized regimens in Parkland’s integrated safety-net clinical provider network. This network serves a large and diverse population of under- and un-insured patients in Dallas County. PCCI is involved in three interlocking studies.

The National Science Foundation (NSF) has awarded joint funding to the University of Texas at Arlington, the University of Texas Southwestern Medical Center, Southern Methodist University, and PCCI to design new machine learning algorithms to solve critical challenges for systematically and integratively mining massive electronic medical records (EMR). PCCI is working closely with a team of advanced mathematicians to develop these clinical prediction models using Bayesian modeling approaches. The grant project seeks to develop new computational tools to automate EMR processing and to improve the EMR for prediction of heart failure (HF) readmission providing support for personalized interventions, innovating emerging EMRs applications and facilitating machine learning and data mining techniques.